This invention has particular application to medical billings made against Workers' Compensation Insurance. Injuries and/or illnesses that occur on the job and are job related (hereafter collectively referred to as injuries) are typically covered under state sponsored Workers' Compensation Insurance. Professional persons, e.g. physicians, chiropractors, etc. (hereafter collectively referred to as providers) who treat such injured persons are required to abide by a set of administrative rules derived specifically to maintain control over costs under Workers' Compensation Insurance benefits.
The rules necessarily deal with all the different types of services provided and the many variables or complications that may develop with any one injury occurrence, which may comprise a combination of injuries. The rules are intended to be all encompassing and adaptable to varying conditions. For example, the rules recognize that more than one doctor may beneficially participate in an operation. On the other hand, only one operating room will be used, one set of attendants, etc. Also, one doctor will more than likely provide follow-up examinations. Thus, as compared to a similar surgery performed by one doctor, the acceptable charges are different and they are not simply doubled just because two doctors are in attendance.
The above is but a very simple example of how the rules vary for determining payment on billings filed against Workers+ Compensation Insurance. Heretofore billings submitted by professional providers (e.g. physicians) for Workers+ Compensation Insurance benefits (numbering in the dozens per day), were divided among insurance company employees who had the responsibility for the accuracy of those billings.
Literally hundreds of rules are applicable and should be considered when processing the billings. Whereas the administrative rules are provided in written form in rule books which are readily available, the first requirement for effectively processing a billing is to be able to recognize when an exception to a general or basic rule exists, and exceptions are frequent. To have to go digging through the rule books when an exception is even suspected creates a log jam of unprocessed billings or requires so many processors as to render the solution more painful than the problem.
Other problems can be cited but the unavoidable result was that due to the sheer complexity of the rules thousands of dollars were likely paid out daily in excess of the acceptable amount. This situation occurred without any question of integrity or competency. It was simply a product of expedience.